Learning outcomes

Managing pain

• Apply general approaches to managing pain to specific patients and describe how the pathophysiology of pain informs these approaches
• Evaluate the pharmacological treatment of pain based on the consumer’s circumstances, the appropriate use of non-pharmacological approaches, and the benefits and risks of medicines used for pain, and
• Support consumers to safely and effectively manage pain

Cancer pain

• Identify the different types of pain that can arise in cancer and assess the pharmacological management of cancer pain
• Evaluate and provide advice regarding dosing of opioids in cancer pain, including calculating the total opioid dose, recommending opioid doses for patients switching opioids and recommending an appropriate opioid dose for breakthrough pain
• Describe the principles of palliative care

Rheumatology

• Describe the common presentations and differences between of rheumatoid arthritis, osteoarthritis and gout
• Evaluate the pharmacological management of patients with rheumatoid arthritis, osteoarthritis and gout, based on the consumer’s circumstances and goals of treatment and the risks and benefits of medicines used to manage these conditions
• Support consumers to safely and effectively use medicines to manage rheumatoid arthritis, osteoarthritis and gout

Sharon, 61 years

Sharon is about to have a knee replacement

Before surgery

• Piroxicam is a long-acting NSAID; need to take this into consideration when ceasing before surgery
• Ensure adequate pain control perioperatively
• Start planning for medication after surgery: will piroxicam be needed?

During/after surgery

• Avoid piroxicam: ‘triple whammy’ with candesartan/HCT, especially when combined with surgery
• Pain relief during and after surgery is likely to rely on opioids (patient-controlled analgesia)
• Oxycodone when back on oral medication—important to use while in pain, equally important to have a plan for stopping as soon as possible

Which one is different

• Tramadol
• Oxycodone
• Morphine

Which one is different

• Fentanyl
• Morphine
• Methadone

Which one is different

• Tapentadol
• Tramadol
• Buprenorphine

Which one is different

• Piroxicam
• Ibuprofen
• Meloxicam

Which one is different

• Tofacitinib
• Golimumab
• Adalimumab

UQ Poll

Beverly

• Beverly is 40 years old (and is 65kg). She has been finding it harder to get the kids ready for school in the morning due to pain in her hands

• Her key symptoms

  • Pain, swelling and reduced movement in joints of both hands

  • Morning stiffness that lasts for about 2 hours

  • Fatigue

• Current medications include: thryoxine 150\(\mu\)g, paracetamol 1g PRN and glucosamine

Initial treatment Which of the following is MOST LIKELY as INITIAL treatment for Beverly’s symptoms

A. Regular paracetamol

B. Diclofenac 50mg TDS

C. Fish oil

D. Methotrexate 10mg WEEKLY

E. Etanercept therapy

Beverly: investigations

• Beverly’s mother suffers from rheumatoid arthritis, she was diagnosed at 52 years of age

• GP sends Beverly for blood tests, and X-rays

  Test	Results
  Rheumatoid Factor	Positive
  C-reactive protein	Elevated
  X-rays	Limited evidence of joint erosion

Diagnosis

Beverly is diagnosed with rheumatoid arthritis.

Which of the following is the MOST appropriate first-line therapy for long-term disease control?

A. Diclofenac or Celecoxib

B. Hydroxychloroquine

C. Methotrexate 10mg WEEKLY

D. Etanercept therapy

E. Methotrexate or Etanercept

What adverse effects are common with initial treatment of methotrexate?

What options are available to help manage these adverse effects?

Which of the following will be considered FIRST if methotrexate is only partly effective for Beverly?

A. Stop methotrexate

B. Add another DMARD (hydroxychloroquine, sulphasalazine)

C. Start cytokine modulator (bDMARD)

D. Increase NSAID

E. Add corticosteroids

Additional RA questions

• What is the treatment goal in RA?
• What is the role of biologic DMARDs?
• What is the role of pharmacists in relation to bDMARDs?
  • Can pharmacists administer bDMARDs?
  • Can pharmacists substitute biosimilars?

William

William is 53 years old and has chronic non-specific low back pain. His back pain started 2 years ago when he was doing some home renovations.

He describes his back pain as relatively constant, it occasionally radiates down both buttocks and hamstrings. At times he experiences a shooting pain up his spine or towards his buttocks.

His pain effects his sleep, relationships and work.

His current medications are

• Paracetamol 500 mg/codeine 30 mg, 2 tablets four times a day PRN (usually takes 4 to 6 tablets a day)
• Tapentadol 100 mg controlled release tablets, 1 tablet twice a day
• Citalopram 20 mg tablets, 1 tablet in the morning
• Pregabalin 150 mg capsules, 1 capsule twice a day
• Celecoxib 200 mg capsules, 1 capsule twice a day

Potential drug-related problems

• High risk of opioid-related harm.
  • Multiple opioids, chronic pain, depression and is taking additional psychotropics (citalopram, pregabalin).
• Moderate risk of NSAID-related harms (celecoxib): possible PUD, effect on renal function
• Low-to-moderate risk of serotonin syndrome (mixed advice): codeine, tapentadol, citalopram

Take home naloxone

• Department of Health information and SHPA Guidance

Identifying patients at higher-risk of opioid-related harm who might benefit from take-home naloxone (Bui et al., 2022):

Making decisions about NSAIDs

Can NSAIDs be differentiated according to…

• Risk of peptic ulcer disease
• Risk of causing renal impairment/injury
• Risk of thromboembolic events
• Effectiveness

Making decisions about opioids

• When is immediate release appropriate/inappropriate?
• When is sustained release appropriate/inappropriate?
• Risk identification, risk mitigation: shared responsibilities with prescribers
• How to avoid opioids in chronic pain?